Approach to the problem of pneumonia in long-term care facilities

Characteristics of Long-Term–Care Facility Residents Associated With Receipt of Influenza and Pneumococcal Vaccinations

Background:

Studies have found residency in long-term–care facilities (LTCFs) a risk factor for influenza and pneumonia and have demonstrated that vaccinations against these diseases reduce the risk of disease. However, rates are below Healthy People 2010 goals of 90% for LTCFs. During 1999–2002, a multi-state demonstration project was conducted in LTCFs to implement standing orders programs for immunizations.

Objective:

Identify nursing home resident–specific characteristics associated with vaccination coverage at baseline.

Methods:

Facility-level data were collected from self-reported surveys of selected nursing homes in 14 states and from the On-line Survey and Certification Reporting System. Resident-level data, including demographics and physical functioning, were obtained from the Centers for Medicare & Medicaid Services' Minimum Data Set; 2000–2001 vaccination status was obtained by chart review. Influenza vaccination status reflected a single season, whereas pneumococcal vaccination status reflected vaccination in the past. Multilevel analysis was used to control for facility-level variation.

Results:

Of 22,188 residents sampled in 249 LTCFs, complete data were obtained for 20,516 (92%). The average coverage for immunizations was 58.5% ± 0.7% for influenza and 34.6% ± 0.3% for pneumococcal. On bivariate analyses, residents with cognitive, psychiatric, or neurologic problems were more likely to be vaccinated; those with accidental injuries, unstable conditions, or cancer were less likely to receive either vaccine. On multilevel analysis, the strongest resident characteristics associated with receipt of immunizations, controlling facility variation, were cognitive deficits and psychiatric illness.

Conclusion:

The variation in baseline vaccination coverage associated with LTCF resident characteristics supports the need for strategies to increase vaccination coverage in LTCFs.

Racial/Ethnic Disparities in Preventive Care Practice Among U.S. Nursing Home Residents

Objective: To assess racial/ethnic disparities in preventive care practices among U.S. nursing home residents. Method: To implement the Institute of Medicine definition of health care disparity, we used the rank-and-replace adjustment method to assess the disparity in receipt of eight preventive care services among residents and evaluate trends in disparities. The sampling design (stratification and clustering) was accounted for using Stata 11. Results: The 2004 National Nursing Home Surveys data show White residents were more likely to have pain management, scheduled toilet plan/bladder retraining, influenza vaccination, and pneumococcal vaccination than Black residents. White residents were also more likely to have scheduled toilet plan/bladder retraining than residents of Other race/ethnicity. Significant Black–White disparities in receipt of influenza vaccination and pneumococcal vaccination were found. Time trend analysis showed that disparities were neither exacerbated nor reduced. Conclusion: Persistent racial/ethnic disparities in preventive care among nursing home residents exist. We urge the development and implementation of targeted interventions to improve the quality of preventive care in nursing homes.

Comparison of severity predictive rules for hospitalised nursing home-acquired pneumonia in Korea: a retrospective observational study

BACKGROUND

Nursing home-acquired pneumonia (NHAP) is the leading cause of death among long-term care residents.

AIMS

To compare current scoring indices (NHAP model score, Pneumonia Severity Index (PSI), CURB-65 (confusion, urea nitrogen, respiratory rate, blood pressure, age >65 years) and SOAR (systolic blood pressure, oxygenation, age, respiratory rate)) in predicting mortality and admission to the intensive care unit (ICU) in patients with NHAP.

METHODS

This retrospective observational study was conducted between July 2008 and June 2011 using data from the Korean Nursing Home Networks. Two hundred and eight nursing home residents were hospitalised with pneumonia in one general hospital. The primary outcome measure was 30-day all-cause mortality. Secondary outcome measures were intensive respiratory or vasopressor support (IRVS), and severe pneumonia (ICU admission or IRVS).

RESULTS

PSI class V showed the highest Youden index (0.45), specificity (66.7%), positive predictive value (PPV, 40.0%), negative predictive value (NPV, 91.5%), and area under the curve (AUC, 0.73) for 30-day mortality. For severe pneumonia, PSI class V showed the highest Youden index (0.40), specificity (72.8%), PPV (62.2%), NPV (77.1%), and AUC (0.70). Similarly, PSI class V showed the highest Youden index (0.35), specificity (68.3%), PPV (51.1%), NPV (80.5%), and AUC (0.69) for IRVS.

CONCLUSIONS

The PSI has superior discriminatory power in predicting all three clinical outcomes (30-day mortality, severe pneumonia, and IVRS) compared with the NHAP model score, CURB-65 and SOAR.

Delirium in long-term care setting: indicator to severe morbidity

We aimed to investigate the incidence and characterize predictors associated with delirium in elderly demented and functionally dependent LTC patients. Data collection included: demographic, clinical, functional, nutritional and cognitive data as well as blood counts and chemistry analysis. The tools used to detect delirium were the Confusion Assessment Method (CAM) and the Delirium Rating Scale (DRS), supported by clinical observation. The occurrence of delirium was 34%. The predominant primary etiologies for delirium were infections (58%), following by metabolic abnormalities (36%), and adverse drug effects (18%). The mean duration of delirium was 15.74 days (2-96 days). Independent predictors influencing duration of delirium were low plasma albumin level, high number of comorbid diseases, male gender, advanced age and presence of CVD. Complete resolution of the delirium was found in 33% (30/92), with persistence in 12% (11/92), and no change in 8% (7/92) of the patients. Forty-eight percent (44/92) of the patients died. Most deaths (50%) were in the first month. The main cause of death was infection related (70%), of which bronchopneumonia was predominant (39%), followed by sepsis (32%). Independent predictors of death were infection, advanced age, low plasma albumin level, dehydration and CHF. The early recognition, identification, correction and treatment of underlying conditions especially in very demented, uncooperative and functionally dependent patients may influence their outcome. Any changes in cognitive and functional status are critical in monitoring LTC patients.

Racial disparities in receipt of influenza and pneumococcus vaccinations among US nursing-home residents

OBJECTIVES

We examined racial disparities in receipt and documentation of influenza and pneumococcus vaccinations among nursing-home residents.

METHODS

We performed secondary analyses of data from a nationally representative survey of White (n = 11 448) and Black (n = 1174) nursing-home residents in 2004. Bivariate and multivariate analyses determined racial disparities in receipt of influenza vaccination in 2003 and 2004, receipt of pneumococcus vaccination ever, and having a documented history for each vaccination.

RESULTS

The overall vaccination rate was 76.2% for influenza and 48.5% for pneumococcus infection. Compared with Whites, Blacks showed a 13% lower vaccination rate and a 5% higher undocumentation rate for influenza, and a 15% lower vaccination rate and a 7% higher undocumentation rate for pneumococcus. For influenza, the odds ratio (OR) for Blacks being unvaccinated was 1.84 (P < or = .001), and the OR for Blacks having undocumented vaccination was 1.85 (P = .001). For pneumococcus infection, the OR for Blacks being unvaccinated was 1.70 (P < or = .001), and the OR for Blacks having undocumented vaccination was 1.95 (P < or = .001). Stratified analyses confirmed persistent racial disparities among subpopulations.

CONCLUSIONS

Racial disparities exist in vaccination coverage among US nursing-home residents. Targeted interventions to improve vaccination coverage for minority nursing-home residents are warranted.

Nursing home resident and facility characteristics associated with pneumococcal vaccination: national nursing home survey, 1995-1999

OBJECTIVES

To assess Advisory Committee for Immunization Practices recommendations for the pneumococcal vaccine in nursing home residents using national surveys to examine factors associated with vaccination.

DESIGN

Cross-sectional national sample surveys of nursing homes and nursing home residents with a two-stage probability design, stratified on size and Medicare and Medicaid certification status.

SETTING

U.S. nursing homes during 1995, 1997, and 1999.

PARTICIPANTS

Six current residents were randomly selected from each facility (n=approximately 8,000 each year).

MEASUREMENTS

Residents' pneumococcal vaccination status was obtained by asking the facility respondent for each resident: "Has [the resident] EVER had a pneumococcal vaccine, that is a pneumonia vaccination?" Vaccination status was coded as yes, no, and unknown.

RESULTS

The proportion of residents aged 65 and older that received pneumococcal vaccination increased significantly, from 23.6% in 1995 to 28.2% in 1997 to 37.4% in 1999 (P<.001). The proportion of residents in homes with pneumococcal immunization programs increased significantly, from 65.2% in 1995 to 88.9% in 1999.

CONCLUSION

The proportion of nursing home residents aged 65 and older receiving the pneumococcal vaccine increased significantly from 1995 to 1999. Residents living in nursing homes with programs for pneumococcal immunizations were significantly more likely to be vaccinated.

Factors Predictive of Increased Influenza and Pneumococcal Vaccination Coverage in Long-term Care Facilities: The CMS-CDC Standing Orders Program Project

BACKGROUND

Between 1999 and 2002, a multistate demonstration project was conducted in long-term care facilities (LTCFs) to encourage implementation of standing orders programs (SOP) as evidence-based vaccine delivery strategies to increase influenza and pneumococcal vaccination coverage in LTCFs.

OBJECTIVE

Examine predictors of increase in influenza and pneumococcal vaccination coverage in LTCFs.

DESIGN

Intervention study. Self-administered surveys of LTCFs merged with data from OSCAR (On-line Survey Certification and Reporting System) and immunization coverage was abstracted from residents' medical charts in LTCFs.

SETTING AND PARTICIPANTS

Twenty LTCFs were sampled from 9 intervention and 5 control states in the 2000 to 2001 influenza season for baseline and during the 2001 to 2002 influenza season for postintervention.

INTERVENTION

Each state's quality improvement organization (QIO) promoted the use of standing orders for immunizations as well as other strategies to increase immunization coverage among LTCF residents.

MAIN OUTCOME MEASURES

Multivariate analysis included Poisson regression to determine independent predictors of at least a 10 percentage-point increase in facility influenza and pneumococcal vaccination coverage.

RESULTS

Forty-two (20%) and 59 (28%) of the facilities had at least a 10 percentage-point increase in influenza and pneumococcal immunizations, respectively. In the multivariate analysis, predictors associated with increase in influenza vaccination coverage included adoption of requirement in written immunization protocol to document refusals, less-demanding consent requirements, lower baseline influenza coverage, and small facility size. Factors associated with increase in pneumococcal vaccination coverage included adoption of recording pneumococcal immunizations in a consistent place, affiliation with a multifacility chain, and provision of resource materials.

CONCLUSIONS

To improve the health of LTCF residents, strategies should be considered that increase immunization coverage, including written protocol for immunizations and documentation of refusals, documenting vaccination status in a consistent place in medical records, and minimal consent requirements for vaccinations.